Basic Information
| Provider Information | |||||||||
| NPI: | 1750329660 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GANATRA | ||||||||
| FirstName: | KOSHA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5912 BOLSA AVE | ||||||||
| Address2: | STE 201 | ||||||||
| City: | HUNTINGTON BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926491146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148985732 | ||||||||
| FaxNumber: | 7149014058 | ||||||||
| Practice Location | |||||||||
| Address1: | 11550 INDIAN HILLS RD | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | MISSION HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913451200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188374327 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 05/28/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | HA4126 | CA | N | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist | 237600000X | AU2163 | CA | Y | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
ID Information
| ID | Type | State | Issuer | Description | AU0021630 | 05 | CA | MEDICAID |